We may disagree about whether a sick or incapacitated person should be helped to end their life if they wish to die, but at least the subject is no longer taboo. Yet most of the half a million people who will die in Britain this year will not fade away painlessly as they sleep in their beds. Fifty-five percent of us die in hospital, 17% in a care home and only a fifth in our own homes. That first percentage, as the Department of Health's End of Life Care Strategy noted a few weeks ago, is falling very slowly. It must fall further if people are to have more say in the manner and place in which they die.
The debate over the availability of drugs that extend life among patients with terminal cancer throws what Nice calls Qaly (quality adjusted life year) into distressing relief. For people who want to live a little longer, perhaps to see a new grandchild or simply through that most overwhelming of terrors – the fear of death – these cost-benefit analyses are of colossal importance. Indeed, Nice drew up fresh guidelines for this new wave of drugs last year and has since approved half of them. Yet, as research in the New England Journal of Medicine recently suggested, giving terminally ill patients what doctors describe as "early palliative care" – encouraging them to consider the treatment they wanted in their final months – can reduce the depression and physical pain they experience.
Doctors and nurses are keen to draw a distinction between palliative medicine – which is sometimes taken to mean high doses of morphine at the very end of life – and palliative care, with the psychological support it offers to the dying and their relatives, as well as pain relief. Indeed, those who chose the latter course lived longer than the cohort who opted for the new wave of life-extending drugs. In a New Yorker article about a 34-year-old mother with lung cancer, the US surgeon Atul Gawande has challenged the medical profession's emphasis on prolonging life rather than trying to improve it. It makes for harrowing reading.
It is much easier to simply say that one cannot place a value on a human life – even as we must, and do: witness the fact that some primary care trusts made no new investment in end-of-life care during the last financial year, while the most generous spent £5.4m. It so happens that hospital deaths and new cancer drugs usually cost more than palliative care at home. But that should not close our minds to the possibility – particularly as the NHS undergoes profound changes – that postponing death is not always the best way to confront it. How people die, as the hospice founder Dame Cicely Saunders remarked, stays in the memory of those who live on.
